It’s the stories of the doctors and nurses that often hit the hardest.
Professionals, trying to do what they always do: save lives. But the coronavirus was too much.
It overwhelmed the paramedics and the emergency departments, filled corridors with frightened patients, forced decisions no doctor or nurse ever wants to make: who gets a ventilator, who lives, who dies.
Even behind their masks, the pictures captured the anguished, the heartbroken, the wrung-out women and men who had given their all, and them some. But it wasn’t enough.
Sometimes bodies have been buried in pits, with coffins stacked on top of each other.
It sounds like something you might have heard about happening hundreds of years ago. Now, if it was happening now, it was likely in some far-off country.
But not this time. Money and modern medicine could not prevent the unfolding horror that left millions in ‘first world’ cities cowering in fear that the COVID-19 grim reaper would come for them next.
No ‘one size fits all’ explanation
We have all been told of the slow responses, the lack of testing kits and shortages of personal protective gear. And, of course, Australia has been a standout success amongst the wealthy nations.
But there are some simple reasons why others in our cohort of privilege have failed so badly. According to experts, it comes down to a number of factors.
But perhaps the most stark is the fact that the US, UK, Italy, France and Spain currently account for a shocking 70 per cent of all deaths.
Each of them is rich, with a sophisticated health system. And while their deadly curves are being ironed out, there is a lethal legacy already, with the threat of future waves to come.
Russia and Brazil are now threatening to join them at the top of these grim charts.
But many poorer and middle-income nations have, so far at least, largely been spared the carnage of wealthier countries.
There is no ‘one size fits all’ explanation – every single nation, including Australia, has its own coronavirus twists and turns – but there are some general observations that seem to make sense.
The deadly impact of international travel
The worst-hit countries are amongst the most mobile and are home to some of the world’s busiest airports, handling hundreds of millions of passengers each year.
People in richer countries have the luxury of international travel and enjoy strong global trade links, particularly with China, where the outbreak evolved.
The affluence that allowed for this international travel undoubtedly spread the virus quickly and efficiently.
This reduced the reaction time and proved a curse for cosmopolitan cities like New York, London and Paris. Their very desirability as international centers was, in part, their downfall.
The lower levels of travel to low to middle-income countries could help explain why they were able to escape the virus, at least in the early days of the pandemic.
According to Professor Tony Blakely, an epidemiologist and public health specialist at the University of Melbourne, this gave them “time to prepare and do some form of physical distancing”.
“[It wasn’t a] silver bullet, but that extra time meant they were not as far advanced in their epidemic and they have had more ability to put control in place, “he told the ABC.
“The virus got out of China and then went to close East Asian countries, and then by travel went to Europe and North America very quickly rather than, say, to India or Africa.”
Dr Abrar Chughtai, an epidemiologist in the School of Public Health and Community Medicine at UNSW Sydney, agrees that the low number of “seeding cases” could help explain why some countries have done very well so far.
“To start a pandemic you need a number of seeding cases in the community,” he said.
“In Australia we don’t have a high number of cases, but it happened in the US and [other countries], where they did see a high number of cases possibly due to high travel.
“So, the human travel trends might be important to look at.”
But that apparent advantage for many poorer countries may rapidly disappear as the virus starts to take hold in those countries in the coming weeks.
The impact of health and demographics
Unlike the Spanish flu of 100 years ago, which killed young, otherwise healthy adults in their millions, this time it’s the old who are at greater risk.
Professor Blakely says age – and by extension aging populations – is certainly one factor in how the coronavirus could impact some countries.
“From nearly infinitesimally small for someone under 20… a one in 10,000 chance [of probability of dying], and then up to north of 10 per cent, maybe even 15 per cent, if you’re over 80. “
Professor Blakely says the younger age structure of some of the low and middle-income countries might act “a little bit like herd immunity”.
“It’s like having more of your population at an age where they don’t transmit it as easily, I think that’s probably happening to some extent, though it’s speculation on my part,” he said.
Mary-Louise McLaws, who is a member of the World Health Organization’s Health Emergencies Program Experts Advisory Panel for Infection Prevention and Control Preparedness, Readiness and Response to COVID-19, says age has been a huge factor.
“In Italy, they have the highest proportion of an elderly population of anywhere in Europe,” she told the ABC.
“So it’s about a quarter are 65 and over, and they have of course, high rates of smoking, plus high levels of comorbidities.”
Why have middle-income Asian countries done well?
It comes down to experience and preparation. For middle-income Asian nations, this is not their first pandemic threat.
Swine flu in 2009, bird flu in the 1990s, and SARS in 2003 were concentrated in Asian countries, giving South Korea, Malaysia, Hong Kong and Taiwan more recent experience with dangerous viruses.
As a result the lockdowns happened quickly, as did mass testing and high tech contact tracing procedures.
Professor Blakley says their exposure to SARS in some ways prepared them for this recent pandemic.
“They’ve got the systems in place. They know what they’re doing. They acted fast,” he said.
“They knew what the threats were, and definitely previous dealings with having to manage SARS have made those countries far better positioned to respond to COVID.”
Professor Jodie McVernon, the Doherty Institute’s epidemiology director, also says countries like Hong Kong, Singapore and South Korea invested in strong public health systems and extensive laboratory capacity, “which were actually the critical elements of initial response”.
“Early border closures to reduce the risk of imported infections were also influential and were a key difference between Australia’s response and the US [and] Europe, “she told the ABC.
So did the West get complacent?
If you look at the Global Health Security Index list, preparation – in terms of good health care, resources and stockpiles – didn’t necessarily translate to containing the coronavirus.
Professor McLaws says while a lack of recent experience in some developed countries may have played a role, tackling the spread of coronavirus also came down to leadership and governance.
“One of the reasons Taiwan has done so well is because they organized their ventilators very early on, and closed their borders to China as soon as they heard about what was going on,” she said.
She also says the WHO proclaimed a public health emergency of international concern on January 30, so “none of those 194 countries could possibly suggest that they did not know”.
“Everyone had a heads up,” she said.
“So for those countries that may try to say they didn’t have enough time to prepare, it’s disingenuous.
“They did not need to wait until March 11, until WHO called a pandemic – that was an academic exercise.”
But can you trust the data?
In a word, no. There are so many variables, with capacities, capabilities and honesty far from guaranteed.
In Britain, deaths in aged care facilities and in people’s homes weren’t counted for weeks.
Demographers also have disputed Russia’s relatively low death toll, given Moscow’s mortality rate for April alone appears to be up by almost 20 per cent.
And according to the Johns Hopkins University research, more than 16 per cent of all confirmed COVID-19-infected patients in Belgium have died.
In France it’s 15.3 per cent, the UK 14.1 per cent, Spain 11.9 per cent and Sweden 12.3 per cent.
Interestingly, while the US has the highest actual death toll, the ratio of deaths to recorded COVID-19 cases is 5.5 per cent. In Australia, it’s just 1.5 per cent.
But there are a number of variables that need to be factored in, including the rate of testing, the methods of recording deaths and even suspicions of cover-ups in some countries.
Professor McLaws acknowledges “the mortality rates are often incorrectly calculated” and in some cases, are “probably higher than what’s being given”.
There might also be an unreported shadow pandemic unfolding in developing nations, which will become more apparent as time goes on.
“It’s already in Africa, but some of the problems are that they don’t have a surveillance system that is anywhere near to the level of well-resourced countries,” Professor McLaws said.
“So a lot of deaths will go unattributed to COVID-19 and a lot of morbidity and future death down the track, as it can take people up to 30 days to die.”
Professor McVernon agrees that deaths in some low-income countries may become more apparent down the track, but she also says poverty or low levels of income doesn’t necessarily guarantee a disaster.
She says some lower-income nations like Vietnam and Thailand have marshalled their “excellent and well established health systems” to manage the spread, while other nations like Cambodia and Papua New Guinea have experienced “sporadic cases”.
The world is only at the beginning of its coronavirus journey
Australia’s deputy chief medical officer Paul Kelly also suggests that testing and data might give us a false sense that people in high-income nations are dying at greater numbers, and this is not a disease of the rich.
While the bald figures indicate a failure to act quickly or effectively in the worst-hit and richest nations, most experts agree it is too early to draw definitive answers.
Yes, complacency and overconfidence played their part and undoubtedly cost tens of thousands of lives, but older demographics and comorbidity factors also had a role.
So if we were to cast this as an affluence virus, we would only be partly right. That’s because wealthy nations like ours, New Zealand, Germany and Greece were able to suppress the spread through early and tough action.
And while the lockdowns and restrictions seem to have lasted an eternity, this is just the beginning.
Countries like Australia that have done well, may not do so in the future. And if, as expected, COVID-19 hits the poorest countries hard in the coming months, there may well be a leveling effect to come.
We really are in the dense fog of this long, painful war. Only hindsight will reveal the complex cat’s cradle of cause, reaction and effect.
But from the vantage point of the here and now, the images of shattered doctors and nurses, and ambulances waiting for hours on emergency department ramps, speak clearly of failure in the very countries that should have been best prepared.